HospitalInspections.org

Based on a review of medical records and documentation, it was determined that the Critical Access Hospital failed to ensure the maintainance of a record for each patient receiving health care services that included a brief summary of the episode, disposition, and instructions to the patient.

Findings were:

A review of medical records revealed 2 (Patient # 3 and 8) out of 10 patients did not have discharge summaries in their medical records. These discharges occurred more than 30 days prior to this survey.

Facility based policy entitled, "Transcription" stated in part, "DISCHARGE SUMMARIES: This item should be dictated upon the patient's discharge from the hospital, but most especially within 30-days from the date of discharge summary. However, this is not always the case. The physician have 30-days from the date of discharge to complete the discharge summary and/or any signatures."

This lack of a discharge summary in these medical records was confirmed in an interview with staff member # 3 on 03/06/13.